Acute decompression illness following hyperbaric exposure: clinical features of central nervous system involvement

Decompression illness (DCI) is a general term encompassing all pathological changes secondary to reduction of environmental pressure. This condition has two forms: decompression sickness (DCS) and arterial gas embolism (AGE) secondary to pulmonary barotrauma. Moreover, DCS is categorized as minor, such as limb and/or joint pains or skin rash (Type I), and serious, as in cardiopulmonary and/or central nervous system involvements (Type II). Cerebral and spinal injuries have been symptomatically classified into AGE and DCS. Brain scans of patients with AGE or DCS showed multiple cerebral infarctions in the terminal and/or border zones of the cerebral arteries. Brain involvements of patients in both AGE and DCS show no differences in neurological or neuro-radiological findings. From the neurological and radiological standpoint, it is therefore impossible to distinguish these two conditions. Despite established treatments for neurological DCI (both AGE and DCS), it is unclear whether US Navy treatment Table 6 is preferable to standard hyperbaric oxygen therapy such as 2.4 atmospheres pressure for 90 minutes. Japanese laws and regulations have peculiarities that permit air diving to 90 meters depth, but with explicit prohibition of the use of oxygen for decompression, albeit a limited use of mixed gas is permissible. Moreover, currently the health screening for hyperbaric workers does not include detailed examination of the cardiopulmonary or the central nervous system.     

Microsurgical anatomy of cerebral revascularization. Part I: anterior circulation

OBJECT: Revascularization is an important component of treatment for complex aneurysms that require parent vessel occlusion, skull base tumors that involve major vessels, and certain ischemic diseases. In this study, the authors examined the microsurgical anatomy of cerebral revascularization in the anterior circulation by demonstrating various procedures for bypass surgery. METHODS: Twenty-five adult cadaveric specimens were studied, using 3 to 40 magnification, after the arteries and veins had been perfused with colored silicone. The microsurgical anatomy of cerebral revascularization in the anterior circulation was examined with the focus on the donor, recipient, and graft vessels. The techniques discussed in this paper include the superficial temporal artery (STA)-middle cerebral artery (MCA), middle meningeal artery (MMA)-MCA, and side-to-side anastomoses; short arterial and venous interposition grafting; and external carotid artery/internal carotid artery (ICA)-M2 and ICA-ICA bypasses. Bypass procedures for cerebral revascularization are divided into two categories depending on their flow volume: low-flow and high-flow bypasses. A low-flow bypass, such as the STA-MCA anastomosis, is used to cover a relatively small area, whereas a high-flow bypass, such as the ICA-ICA anastomosis, is used for larger areas. Cerebral revascularization techniques are also divided into two types depending on the graft materials: pedicled arterial grafts, such as STA and occipital artery grafts, and free venous or arterial grafts, which are usually saphenous vein and radial artery grafts. Pedicled arterial grafts are mainly used for low-flow bypasses, whereas venous or arterial grafts are used for high-flow bypasses. CONCLUSIONS: It is important to understand the methods of bypass procedures and to consider indications in which cerebral revascularization is needed.     

The pedipump: development status of a new pediatric ventricular assist device

The PediPump is a new rotary dynamic ventricular assist device designed specifically for pediatric applications. Although it is capable of providing support for adults, the small size of the PediPump makes it suitable for newborn circulatory support while retaining excellent hemodynamics. Current and future development plans include: (1) determination of the basic engineering requirements for hardware and control logic, including design analysis for system sizing, evaluation of control concepts and bench testing of prototypes; (2) performance of preclinical anatomical fitting studies using computed tomography-based three-dimensional modeling; and, (3) evaluation with animal studies to provide characterization and reliability testing of the device.     

Plasma concentrations of brain natriuretic peptide in patients with acute ischemic stroke

BACKGROUND: Acute blood pressure (BP) elevation and cardiac abnormalities are known to follow ischemic stroke. Brain natriuretic peptide (BNP), which is produced in response to such cardiovascular alterations, is expected to play a hemodynamic role. We measured plasma BNP concentrations in patients with cerebral infarction (CI) to determine the implications of BNP in acute ischemic stroke. METHODS: Eighty-eight patients with CI, 59 with essential hypertension, 44 with spontaneous intracerebral hemorrhage, 22 with asymptomatic atrial fibrillation (Af), and 20 age- and sex-matched healthy volunteers were recruited in the study. CI patients were divided into 2 subgroups either having Af (27 patients) or not (61 patients). BNP levels were repeatedly measured in 58 patients with CI. BNP levels were compared between ischemic subgroups categorized by size of infarction. Correlation was investigated between BNP levels and hemodynamic parameters. RESULTS: BNP levels in CI patients were significantly higher, but they decreased in the subacute period. BNP levels in CI patients without Af were correlated with mean arterial blood pressure (MAP) on admission or the degree of reduction in MAP at day 1, while in CI patients with Af BNP levels showed negative correlation with MAP on admission. Follow-up serum sodium levels in CI patients with Af were negatively correlated with BNP levels on admission. CONCLUSIONS: This study suggests the hemodynamic implications of BNP in acute ischemic patients.     

Reduction of radiation dose at HRCT of the temporal bone in children

PURPOSE: The purpose of this study was to reduce the radiation exposure of the eye lens in high resolution computed tomography (HRCT) of the temporal bone using an experimental phantom. MATERIALS AND METHODS: The HRCT image that was used for analysis was obtained by changing parameters including effective-mAs (E-mAs), distance coverage, and height of object in the Y-axis. Radiation exposure was measured to calculate equivalent doses by glass rod dosimeters that were fixed above the right orbit parallel to the body axis. Deterioration in image quality was evaluated by three radiologists and the following three-point rating method was employed: grade 1 (good image quality without diagnostic limitations), grade 2 (image was deteriorated, but there were no diagnostic limitations), and grade 3 (image was deteriorated with diagnostic limitations). RESULTS: Assuming that the equivalent dose was y (mSv), and E-mAs was x, a simple regression line, y=0.506x-0.494 (decision coefficient, R2=0.999), was obtained. A standard deviation (S.D.) less than 120 (E-mAs, 220-120) was judged as grade 1, an S.D. between 120 and 150 was judged as grade 2, and an S.D. higher than 150 was judged as grade 3, indicating that deterioration of the quality of images with reduced E-mAs affected the diagnosis by imaging at S.D. higher than 150. CONCLUSION: Radiation dose at the eye lens in HRCT could be reduced up to an equivalent dose corresponding to 70 mAs without compromising diagnostic quality in the phantom experiment.     

Increased accumulations of AMsopropyl-p-[123I]-iodoamphetamine related to tumefactive multiple sclerosis

We present a 21-year-old woman with tumefactive multiple sclerosis (MS) that exhibited a rapidly progressive course. There were multiple tumor-mimicking contrast-enhance lesions with surrounding edema and mass effect on magnetic resonance imaging. Both early and delayed brain single photon emission computed tomography (SPECT) with N-isopropyl-p-[123I]-iodoamphetamine demonstrated increased accumulations of the tracer and a high retention on the lesions. The SPECT findings represent a diagnostic pitfall for distinguishing MS from malignant brain tumors in patients with intracranial tumor-like lesions.     

Binding and internalization of Clostridium perfringens iota-toxin in lipid rafts

Clostridium perfringens iota-toxin is a binary toxin composed of an enzymatic component (Ia) and a binding component (Ib). The oligomer of Ib formed in membranes induces endocytosis. We examined the binding and internalization of Ib by using Cy3-labeled Ib. Labeled Ib was retained at the membranes of MDCK cells for 60 min of incubation at 37 degrees C, and later it was detected in cytoplasmic vesicles. To determine whether Ib associates with lipid rafts, we incubated MDCK cells with Ib at 4 or 37 degrees C and fractionated the Triton-insoluble membranes. An Ib complex of 500 kDa was localized at 37 degrees C to the insoluble fractions that fulfilled the criteria of lipid rafts, but it did not form at 4 degrees C. The amount of complex in the raft fraction reached a maximum after 60 min of incubation at 37 degrees C. When the cells that were preincubated with Ib at 4 degrees C were incubated at 37 degrees C, the complex was detected in the raft fraction. The treatment of MDCK cells with methyl-beta-cyclodextrin reduced the localization of the Ib complex to the rafts and the rounding of the cells induced by Ia plus Ib. When 125I-labeled Ia was incubated with the cells in the presence of Ib at 37 degrees C, it was localized in the raft fraction. Surface plasmon resonance analysis revealed that Ia binds to the oligomer of Ib. We conclude that Ib binds to a receptor in membranes and then moves to rafts and that Ia bound to the oligomer of Ib formed in the rafts is internalized.     

Preclinical readiness testing of the Arrow International CorAide left ventricular assist system

BACKGROUND: Left ventricular assist system technologies are currently being developed as effective alternatives to cardiac transplantation. In this study, in vivo testing of the Arrow International CorAide left ventricular assist system was conducted to determine its preclinical readiness based on demonstrated system performance and biocompatibility. METHODS: Arrow International CorAide blood pump assemblies were implanted in 7 calves for 1-month (n = 4) and 3-month (n = 3) durations without the use of chronic anticoagulation therapy. Hemodynamic performance, physiologic pump control, end-organ function, and device-related adverse events were evaluated during the studies and at autopsy. RESULTS: Hemodynamics were stable in all cases with a mean pump flow of 4.1 +/- 0.8 L/min and a mean arterial pressure of 101 +/- 4 mm Hg. In all calves, renal and hepatic function remained normal with no incidence of hemolysis, infection, bleeding, or embolism. The CorAide physiologic control algorithm demonstrated appropriate pump speed and flow adjustments in response to physiologically induced inputs, and the system's external electronic components demonstrated no hardware or software malfunction. All 7 cases were sacrificed electively. Autopsy revealed no sign of end-organ disease on gross and histologic examinations, and no device failure, malfunction, or mechanical wear of the pump blood-bearing surfaces was found. CONCLUSIONS: The Arrow CorAide left ventricular assist system demonstrated effective pump performance and good biocompatibility with no incidence of device-related adverse events. This system has completed its preclinical readiness testing and is approved for clinical trials in Europe in 2003.     

Subcutaneous emphysema during endoscopic resection of the gastric mucosa

A 69-year-old male underwent endoscopic mucosal resection for an early gastric cancer under general anesthesia with sevoflurane and nitrous oxide. Because of gastro-intestinal gas insufflation for endoscopic visualization, abdominal distension was found remarkable and the peak inspiratory pressure increased from 20 cmH2O to 30 cmH2O. About 2.5 hours after initiation of the procedure, iatrogenic perforation was identified endoscopically and emphysema became apparent not only in the scrotum, but also in the subcutaneous tissues of the chest and neck. In order to ameliorate this complication, an emergent distal gastrectomy was performed involving laparotomy. Nitrous oxide should be avoided in endoscopic mucosal resection under general anesthesia to prevent intestinal distension and attention should be paid to subcutaneous emphysema as a sign of perforation of the gastro-intestinal tract.